Cataract at 35 - which lens to choice?

Eye care
1

Hello, I am 35 years old without health problems and without vision problems until yesterday.
I was recently diagnosed with cataracts in my right eye and need immediate surgery. My left eye is healthy, with vision 10/10.
The two ophthalmic surgeons I visited suggested multifocal lenses rather than monofocal. In fact, one of them asked me to choose between Alcon PanOptix Lens and AcrySof IQ Vivity. What scares me, apart from the procedure of syrgery, is the fact that my doctors have made it clear that I will lose some ability and quality of my sight and I have to choose whether I am more interested in having near or far vision.
They are also concerned about the fact that I will have to get used to a different way and function of vision in each of my eyes, as my left will work with its natural lens and my right with the additional multifocal.
Due to my age (35) and work, my vision is the most valuable …
I am very confused and disappointed, as I feel that after the syrgery I will not see better but worse (today even the eye with the cataract has vision 8/10) …
I would be grateful if you could answer some of my questions below:

  • Does anyone have experience with these two lenses Alcon PanOptix Lens and AcrySof IQ Vivity?
    -How does one see with the use of these lenses (I mean how it differs from normal vision), the doctors told me that I will see multiple images and in the process of months my brain will get used to it!!
  • Does anyone have an multifocal len in one eye and a natural len in the other? What is his /her experience with this?

Thanks a lot

2

DG12345

I am not of the opinion that this cataract surgery is urgent. It certainly is isn’t life threatening.

I would be very wary of any surgeon rushing me into a decision. There is a lot to consider and pros and cons no matter which lens you chose. The IOLs being suggested ate premium lenses and the cost of cataract surgery isn’t cheap. Unfortunately greed can play a factor in their rushing you to a decision.

Can your vision still be corrected with glasses or contact lenses? Usually one considers the surgery when vision can no longer be corrected. And in the meantime you should research surgeons and lenses. Take your time and get several consults. Fortunately your eye without cataracts will compensate and offer near vision should you decide on a monofocal lens. monofocal lenses are usually covered by insurance when you have a cataract that requires surgery.

3

I have a MF in one eye and my natural lens in the other.

But first why do you need surgery immediately if you are seeing 8/10 in the cataract eye and 10/10 in the other eye. I know I am a procrastinator as it was years from the day I found out I had a cataract to getting actual surgery and even now that my other eye needs cataract surgery I am procrastinting.

My point is unless you really need immediate surgery, I would suggest to take some time and read up on your option, because all options in Cataract surgery come with tradeoffs and only you can determine which tradeoff is best for you. For example, personally I don’t want either one of those lens you mentioned for my 2nd eye.

Second if an Ophthalmologist said, “choose between Alcon PanOptix Lens and AcrySof IQ Vivity.” I would probably run out the door.

Based on you IOL options I am taking a wild ass guess you are in America and only looking for FDA approved lens.

Before I talk about my experience with MF, I will start out with IMHO the IOL options from least risky to most risky.

1)Monofocal – True and Tried and what most people get. On comment on distance vision. Some people I think are confused by that term. If you look at the defocus curve on a monofocal you should get pretty good vision down to about 2’. As you get in closer; vision quality drops off rapidly.

2)Light Adjustment Lens (LAL) – Many doctors miss the refractive mark (1 Diopter or more) and this lens lets you adjust it after surgery. And from what I read you might be able to adjust it more than once, so you can nail plano or whatever your goal is.

3)Crystalens - You hardly hear about this IOL, but it is supposed to provide excellent distance (no contrast loss) and maybe it will adopt and provide some intermediate and close vision.

4)The “New” EDOF Refractive IOLs (Tecnis Eyhance and IQ Vivity). They don’t give a lot of EDOF. I think the IQ Vivity provides for an extra -0.5D, but that can be an extra line. But these are “NEW” IOLs and so comes the Early Adopter Risk. And personally, I believe there has to be some tradeoff, and am guessing it is contrast sensitivity.

5)Defractive IOLs - Whether be Trifocal or EDOF, they all come with tradeoffs including dysphotopsias.

One of my biggest beefs is Ophthalmologist are not 100% honest with patients about dysphotopsias when pushing defractive IOLs. You should make sure he shows you simulation of what to expect. I am going to attach a photo simulating dysphotopsias. My dysphotopsias fall somewhere between what they show as mild and moderate. If you are not willing to accept this risk, DON’T consider a defractive IOL.

Here is some potential bad news for you and you need to realize it ahead of time. Because you are young and had such good vision prior to surgery, your expectations will probably be a lot higher than what my expectations were as my vision was so bad for so long before surgery.

I have the Tecnis Low Add MF +2.75 in my left eye and my natural lens in my right eye. This means I get dysphotopsias, but the trade-off is worth it to me as I get Functional Close vision. What that means is I can see a menu in a restaurant or read a label at a grocery store. And yea if I find the right sweet spot I can read an article, but to do any serious reading I need a good light and readers. At this point my right eye cataract has gotten so bad I pretty much just see out of the left eye so I am worse than you are.

I want to comment on the statement, “my brain will get used to it!”

I read someone else explanation of what really happens and it was so much better than how I would have explained it I will paste their words and it also applies to defractive EDOF IOLs:

“To be clear, multifocal visual disturbances never “go away”. You can’t change physics. A more accurate thing to say is that the brain habituates to them. The visual disturbances are still there and if you THINK about it you will see then exactly the same as you always have. It’s just that if your DON’T think about it you don’t notice it. You brain learns to “filter them out”. But they’re still there.”

So you will have 2 different lenses. In general you brain will neural adopt and choice the best image presented from the 2 lens, but you can get Depth perception can be impacted by having a difference in the 2 lens.

There is no 1 perfect lens selection for everyone. You really need to take you time and think about what activities are most important to you.

And before I forget it, PLEASE make sure you are using a highly regarding Ophthalmologist. Have they been involved in clinical trials and written papers. Do they have a lot of experience with this particular IOL.

As for me I don’t want another light splitting IOL, as they will effect vision in dim light. I am waiting for Tecnis Synergy (not FDA Approved) or Tecnis Symfony Plus (FDA Approved but not commercially available). The Synergy, hands down, has the best defocus curve I have seen for any IOL. Of course, Real-World results after 100K Plus people have it implanted might tell a different story, so that is what I am waiting to see.

4

I would just add to the other replies saying, unless there’s something we don’t know, with one perfect eye and the other actually not that bad yet, there is no need for surgery right now. In fact depending on how it progresses you may not need surgery for years. I’d wait until driving starts to become an issue. By that time something like the Juvene (the “holy grail” of IOLs) may be available.

5

@Sue.An2 Thanks for your reply
I am also surprised by the pressure of the doctors to undergo surgery immediately, as I can see blurred by the eye with the cataract but with the help of my other eye which is healthy I have no problem in daily activities such as reading, driving etc. and in fact without the use of glasses.
In terms of cost it is indeed high. But as I am 35 years old and I need my eyesight for many more years, I care about the best possible result even if it costs.
I feel despair because what is proposed to me as a solution is worse than my current vision …

6

@rwbil Thank you very much for the answer and the time you spend to explain it all.

I live in Greece, here the following distinction is made between lenses: monofocals for the elderly who are familiar with presbyopia and the use of glasses and multifocals for young people and those who want to get rid of the use of glasses.

The two doctors I saw are considered very good, however I will get other opinions … but no one did an analysis with simulations on how I will see after the surgery and I do not know if there is a doctor here who can do such a thing!!

They told me about halos around the lights with the use of multifocal lenses and difficulty in driving at night, but good near and far vision without the use of glasses. In this forum, however, I find that it is not exactly like that …

They are completely negative in the use of a monofocal len as there will be a great contrast to the visual ability of my other eye with natural len. Also, they consider that my cataract is hereditary and in the coming years it will affect my other eye and I will have to put the same lens that I will choose now in my other eye in the future. So if I choose single focus I will be obliged to wear glasses for all my activities for the rest of my life.

The truth is that I have never use glasses, I always had good vision and I do not know how I would feel not to see well without glasses. I think this will make me feel claustrophobic!

Ideally I would like to see both near and far and use glasses for reading or driving, without other side effects, but such a lens tells me it does not exist !!

7

@david98963 Thanks for your answer.
This is what I would like, the surgery to be done when my vision will be so bad that a len will make me feel that cataract is evolving rapidly and the surgery will become more difficult after months …

8

@david98963
Some words are missing from my answer so I repeat it here:
Τhanks for your advice.
This is what I would like: the surgery to be done in the future, when my vision will be so bad due to cataract, that i will have the impression that the len improves mi vision and not now. However the doctors claim that my cataract is getting worse rapidly and the surgery will become more difficult after a few months.

9

“By that time something like the Juvene (the “holy grail” of IOLs) may be available.”

Been watching that one and at best IMHO it is years away. I would just be happy if they worked on the modular part where that base makes PCO unlikely and makes it easy to change IOLs.

10

They company is saying 2023 but who knows

11

Ok I’m NOT A DOCTOR but if the surgeon is saying it’s progressing rapidly then I assume you’ve been seeing this doctor for a while? There would be no way to judge progression from a single visit. Progression implies a history of visits.

The bottom line is, it’s a cataract. It’s not life threatening. It’s elective surgery. it’s completely up to you when to have it done. Usually the decision point is when people start to notice that driving is difficult.

The place you live will have vision requirements for driving. That’s worth looking into. Where I live you need ONE eye (just one) that’s at least 20/40 or better (so 7/10 I think on your scale). And you have one perfect and one 20/32.

As for progression, it varies. In some people the cataracts get bad quickly. In others it take years. The surgery used to be so invasive that they used to wait until you were almost blind. Now they do it even on people who do NOT have cataracts (for presbyopia).

Personally I would get a second opinion. Again I’m not a doctor but from what you’ve told us I don’t really see what the rush is. It is true that if you wait until the cataract gets really bad it can be more difficult to remove because it’s harder, but I think it would have to be really far gone for that to be any kind of consideration at all.

12

It sounds like the reason they are anti-monofocal is because you are young and your eyes can still focus for close distance. So switching to a monofocal will be a big lifestyle adjustment. That said, monofocals will give you the best vision quality. It just won’t be as functional.. i.e. no ability to focus up close / need glasses / progressives. Older people don’t usually mind this because they’ve probably already been using readers and/or progressives for years or decades. So they know what to expect.

The bottom line is there is only so much light coming into the eye. And IOLs today are just static pieces of plastic. They don’t have the ability to focus / change shape. So in order to give you more focus range they have to rely on tricks.

The trick of a multifocal is to split the light to make 3 separate images that are in focus. Your brain then learns which one to use at any given time. Since a multifocal is splitting the light it might only use 40% of the light for distance (for instance). Obviously you can’t get the same image quality if you’re only using 40% of the light versus 100% of the light (like a monofocal). This light splitting also causes glare, halos and starbursts at night. I believe that’s caused by the stray light that gets lost in the splitting process. Most people get used to it and don’t mind though. The slightly less sharp vision and less contrast and halos are tradeoff’s younger people are often willing to make for the benefit of more functional vision without having to mess with readers all the time (which can be difficult if you have an active lifestyle).

The trick of the new monofocal-plus IOLs like Eyhance and Vivity is to stretch the light out rather than split it. Again though you’re not focusing 100% of the light in one spot so there are still tradeoffs. With Vivity the tradeoff is contrast. With Eyhance I think the tradeoff is just very slightly less sharpness. Very slight. But it’s contrast is as good as a mono. But it’s extension of focus is pretty minimal. It might only give you another 8 inches of closer vision (so you can see clear maybe from 2.5 feet vs. 3 feet).

As for cost, a monofocal should be free through insurance or public health if you have universal healthcare where you live. For anything other than a monofocal you’d typically being going to a private clinic and paying a fair bit of money.

Personally I’m a perfectionist. But I’m also young(ish) at 52. And extremely active (yoga, hiking, running, skating). So the perfectionist in me wants the highest quality, high contrast, super sharp vision of a mono… but the young active me is worried about the pain of having to carry readers everywhere and the pain of putting then on/off/on/off every 2 seconds when you’re shopping or looking for the right key on your keychain or checking your phone / dashboard / price label / etc. Progressives would work or bifocals but you’d have to wear them all the time to get rid of the annoyance of constant switching of glasses on and off for day to day living. And I feel like it might be weird to wear glasses all the time when you have perfect distance vision without them. So for ME personally I think the happy medium may be the Vivity or Eyhance. I personally would not consider a multifocal.

Oh ONE more thing. If you have or ever develop any kind of ocular pathology (glaucoma for instance or macular degeneration) multifocals would be contraindicated. The idea being that, if you already have less than perfect eyes, using a lens that gives you less than perfect image quality (more functional but poorer quality) is a bad idea.

13

By simulation I just meant they show you simulated photos of realistic halos. I forgot to attach the image before.

“They are completely negative in the use of a monofocal len as there will be a great contrast to the visual ability of my other eye with natural len.”

The vast majority of the people in the world get monofocal IOLs. I basically only see out of 1 eye and am surviving. As I was older I already suffered from Presbyopia, so in your case you will notice a bigger difference in the 2 IOLs. At first after my left eye cataract surgery I would do the cover up the right eye left eye thing and I would notice differences. And there were lots of differences, too many to list. Even how a light source would come and hit objects would make a difference. One of the big differences was vision in dim light. I was surprised how much a MF makes things darker. But having said all that I was and am happy with the MF overall.

“I will have to put the same lens that I will choose now in my other eye in the future. So if I choose single focus I will be obliged to wear glasses for all my activities for the rest of my life.”

I find these statements disturbing to put it mildly and disagree with both. There are so many options including monovision. Ron will probably chime in on that option as he has done self-experiments using contacts to simulate the effect. I am a big believer on only doing 1 eye and evaluating the results, because you very much might want to do a mix and match IOL. You absolutely do not have to get the same IOL in both eyes and mix and match is done to give you the best overall vision. I plan to do Mix and Match. I have no plans to get the same outdated MF in my other eye. You want to evaluate the weakness of the first eye and then try to compensate for them in the second. But if you are thrilled with the first eye then by all means get the same lens in the second eye.

BTW if you are in Greece is the Tecnis Synergy not available there? I know how medicine works is different in Greece, but I would look for a TOP Ophthalmologist who has implanted many Tecnis Synergy, IQ Vivity and PanOptics and get their assessment, which should include both the pros and cons. By the way I have self-interest here as I am thinking about the Synergy IOL so want to know what you find out. From what I read that IOL will provide you the best vision at all distance, but I am guessing that comes at the cost of increased dysphotopsias. So if you get too many dysphotopsias that lens might be a great mix and match with Symfony Plus.

You cannot do links here, so here are some videos to look up to get some information on the Tecnis Synergy.

  1. On youtube search for, “Dr. Nikica Gabric Synergy IOL”

2)On Vimeo Search for, “Tecnis Synergy IOL: The Newest Member of the Tecnis Family – Dr. Chang Presentation”

14

Will bet you a steak dinner that lens is not FDA approved in 2023. LOL!!

15

Oh I’m sure. That info was provided “for what it’s worth”. LOL. That said she is in Europe I think? And it seems like all new IOL’s are first available in Europe, then Canada, then the USA. Now sure why that is. But yah 2023 is probably highly optimistic. That’s what the company is saying… but yah. And even then, it’s such a radically new approach that I imagine it may take awhile before clinics even want to use it.

16

I just turned 36 last month and am facing the same choice, which lens and what am I really getting into. Currently, my vision last tested was OD 20/30 Glare 20/100; OS 20/25 -2 Glare 20/70. It is hard to see a lot of things when light is involved. I have everything on the computer in dark mode/high contrast and use very low lighting at work. This works perfect and text is not blurry at all in these modes. However, it isn’t always offered for everything. Bright lights and black text on white paper is just blurry to me from the light. I can read it in very low lighting. I have not had glasses before, except readers that I had to basically beg for to use in some instances. Especially, when my eyes are tired the extra magnification seems to help. I drive with an anti-glare fishing pair of sunglasses all the time. typically day or night.
I have read many of the posts here and am more confused at what the best decision is for me. The surgeon recommends PanOptix if I can live with halos. That is a majority if my issue now and after reading posts here seems like a terrible Idea!!
Vivity was the second recommendation.
Vivity was offered as the option for best range of vision for an active lifestyle. I am confused if I should just go with the mono lenses offered or if the difference with a Vivity would be that different. I had a friend who is older by 10 years who has 20/20 and just got the mono-focal and says his vision did not change just that he does not have the glare. I asked a previous doctor if I chose mono-focal if I would be sacrificing my vision and see worse with a mono-focal lens and was told I absolutely would. I do not want to lose good vision, I just want the glare and halos gone. I still want to be able to put on make up. go to the gun range, read a label in a bright ass grocery store! I am the sole provider for 2 teenagers so the ability to drive day or night, is a big deal. I’m confused the reality of mono lens vs Vivity or something that will cost thousands. If the difference isn’t much, might as well not spend the money? This is where I am at with my choice between the two…

17

The problem is that everyone’s outcome is different and there’s no way to know until you have the surgery done. My dad got monofocals and he can read his watch from less than a foot away! No problem. Maybe he ended up a little too undercorrected. Maybe he ended up with some unintentional monovision. Maybe his cornea shape helps. Who knows. But what the data tells us is that his result is in the 10% range of people (i.e. 90% of people do NOT get this result with a monofocal… not even close).

The best you can probably reliably hope for with a monofocal (but again your milage may vary… could be better or worse) is good visual acuity from 3 feet out (and blurry for anything closer than 3 feet). In reality that might be 6 feet for some people and 2 feet for others… who knows. Either way you use readers, bifocals or progressives to deal with that.

With something like the PanOptix (multifocal) most people will get pretty good vision at 12", 24" and distance. But there can be slightly blurry gaps in-between. And you will lose some contrast. And you’ll have halos. But you have a very good chance of almost never needed glasses for anything.

With Vivity (mono-plus… not really a true EDOF) trial data shows you should get pretty good vision down to 24" and no gaps and no halos but you lose some contrast sensitivity… a little bit more than you lose even with one of the new Multifocals. And you will need glasses for really close up (reading, pill bottles, etc.)

So take in all the information, consider any pre-existing eye conditions (the doctor would test for that), and consider your lifestyle and personality and make a decision and hope for the best. I suspect the vast majority of people are happy with whatever they choose. But they’re not the one’s posting on the internet. You’re only going to find unhappy people posting on the internet. Trials find that well over 90% of people are happy with a multifocal and would do it again. But there is always the risk that you’re one of the few people that hates the halos and never gets used to them.

Personality plays a big role. If you’re a perfectionist / type-A you may not do well with a multifocal. Vivity or Eyhance might be a good middle ground that will give you good enough close vision for all those little day-to-day things without the hassle of putting glasses on/off/on/off every 10 minutes (or progressives) but if you’re sitting down for a couple hours to read or whatever you won’t mind using readers.

18

As others have said, I would not rush into cataract surgery with 10/10 and 8/10 vision. In North America that would be called 20/20 and 20/25. Lots of people do not have that kind of vision even with glasses. Because you are so young, I would put off getting IOL’s as long as possible. You will get older and the lenses available may get better over time.
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Presbyopia correcting lenses have pros and cons. They offer a wider depth of vision but often at the cost of visual side effects. Of the more commonly available and newest of the lenses available here I would rate them in this order:
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Tecnis Eyhance
Alcon AcrySof Vivity IQ
Tecnis Symfony
Alcon PanOptix
Tecnis Synergy
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As you go down the list the lenses offers more depth of focus but also a higher potential for visual artifacts.
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My thoughts with your vision still so good is that you should consider using contacts to simulate monovision to see if you like it. Monovision uses standard aspheric monofocal lenses but the non dominant eye is under corrected by about -1.25 D. Because your vision is so good, you may have to use a +D contact to achieve this difference. This eye then can be used for reading while the other eye is used for distance. Since you are so young, your eyes can probably still change focus, and it will not be a perfect simulation, but it will give you some idea what it is like. The advantage of using monofocal lenses is that you get the best quality of vision without the visual artifacts of the presbyopia lenses. Monovision gives you a functional vision across a wide range of distances.
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I have one eye with a monofocal IOL for distance and get 20/20 vision with it. I can see down to about a half a meter. My other eye has a mild cataract and I correct it with a contact lens to be -1.25 D. It actually works quite well and I almost never uses glasses unless I want to do some really close fine work. But, with the computer, watching TV or driving it is just fine.
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There is no problem with using an IOL in one eye and having the other eye natural. I see a difference when I close one eye or the other, but when they are both open the brain blends the images. The colour from the natural eye is more yellow due to the cataract, and is more dull. The IOL eye is amazingly bright and clear. Overall the image is much brighter and sharper than before when I had the bad cataract in one eye. There is no problem at all with using one natural eye and one IOL eye, especially with your very low refractive error difference. Since you are younger your natural eye will accommodate for distance and should let you read well.
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If I were you I would hold out as long as I could, and then go with a monofocal in the bad eye when you have to. You can probably wait longer for the second eye. And there is no real problem with having a different lens in each eye. About 25% of surgeons now use a different lens. The hope is to cover the weaknesses of one lens with the strengths of the other. In your case for example, you could go with a distance eye first in monofocal (hopefully your dominant eye), and then a Vivity or Symfony in the second eye for reading.
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Hope that helps some,

19

I have seen two different doctors and they both did not recommend using two different lenses. I’m not really sure why other than because of my age. They did not seem to be very confident in Vivity, due to the lack of data or maybe their experience with it. I guess you are right, just hope for the best with whichever I choose. Unfortunately, I cannot wait much longer as driving is becoming more and more difficult each day. If I can have someone else drive me, I do. But options are limited and no public transportation in my area. I’m leaning towards Vivity and wonder if I just get my right eye done and see how that works before deciding to do the left eye. I often cover my right eye (worst cataract issue) and use my left eye to focus on what I am trying to read.

20

One important point is even if you look at a defocus curve for your IOL, the 1 sigma deviation can be quite a bit and not everyone will even fall into that category. So as others have said results will vary.

Reading your concerns I think you might be a good candidate for the light adjustable lens (LAL). Do both your eyes have cataracts or just one.

With the LAL you can have the IOL adjusted after surgery to hit the Plano Mark in your dominate eye. If your other eye does not have a cataract you can use contacts to simulate monovision and see if that works for you and what power level is best.

Then you can get the LAL in the non-dominate eye and nail the monovision power level. Or if a little more gutsy go for the IQ vivity in the non-dominate eye and do -.75D monovision.

This is the least risky option and it should give you most of what you are looking for. I think this will give you great distance and at least functional close. To do serious close-up reading you need readers.